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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202351
Report Date: 04/06/2026
Date Signed: 04/06/2026 06:52:14 PM

Document Has Been Signed on 04/06/2026 06:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BELMONT VILLAGE SUNNYVALEFACILITY NUMBER:
435202351
ADMINISTRATOR/
DIRECTOR:		MANZO, TYLER JFACILITY TYPE:
740
ADDRESS:1039 E EL CAMINO REALTELEPHONE:
(408) 720-8498
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 150CENSUS: 119DATE:
04/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Tyler Manzo and Nadio JonesTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility, which consists of 4 floors; assisted living residents reside on all floors. Memory care residents reside in 21 rooms on ground level and 20 rooms on second floor; both of these units are secured with egress alert devices and have a designated dining room. In addition, there are 7 designated rooms on fourth floor reserved for residents with severe dementia, as well as a separate dining room. Most units have wet bars with small refrigerators. All units have an emergency signal system which consists of pull cords in bathrooms and living areas, which sends an audible alert to staff on their cell phones. Operable carbon monoxide detectors are installed in each apartment. There are no accessible bodies of water or fire safety hazards observed. Emergency drills are conducted monthly and documented. Medications are stored in locked medication carts. A comfortable temperature is maintained, passageways are clear, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and there are benches installed in shower stalls. Hot water temperature tested in clients' bathrooms between 116 and 117 degrees. Fresh and non-perishable food supplies are maintained. Quarterly food and dietary audits are conducted and documented; copy of last audit by registered dietician dated 2/13/26 is provided. First-aid kit is inspected. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed Transcripts of staff training are provided today for review. Random client files are reviewed. Staff records--including training--will be reviewed at a later date.
Executive director Tyler Manzo is a certified RCFE administrator (x 5/27) that oversees facility operations.
The following information is provided to LPA today:
• Proof of current liability insurance
• Personnel Report (LIC500)
• Facility Sketch
• Emergency Disaster Plan (LIC610D)
Deficiency of the California Code of Regulations, Title 22 is cited on following page.
NAME OF LICENSING PROGRAM MANAGER: Cowan April
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/06/2026 06:52 PM - It Cannot Be Edited


Created By: Audrey Jeung On 04/06/2026 at 06:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE SUNNYVALE
FACILITY NUMBER: 435202351

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2026
Section Cited
CCR
87465(h)(2)

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INCIDENTAL MEDICAL CARE
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met, as client #8 is not able to self store/admin
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Ibuprofen, Tylenol and Tumms were removed from client's bathroom in LPA's presence
Deficiency corrected and cleared
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medications, per MD, but Ibuprophen (2), Tylenol and Tumms are stored in bathroom. Licensee failed to ensure that medications are inaccessible to clients who cannot self store/admin meds, which poses an immediate health or safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2026


LIC809 (FAS) - (06/04)
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